Healthcare Provider Details

I. General information

NPI: 1568139392
Provider Name (Legal Business Name): TIMOTHY BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2021
Last Update Date: 08/28/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11825 MAJOR ST
CULVER CITY CA
90230-6356
US

IV. Provider business mailing address

4750 LINCOLN BLVD APT 150
MARINA DEL REY CA
90292-6981
US

V. Phone/Fax

Practice location:
  • Phone: 310-915-6100
  • Fax:
Mailing address:
  • Phone: 510-734-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000024410
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT300678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: